Buckingham Pavilion

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were properly labeled and dated. These failures have the potential to affect all 110 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident (R101) took their medication, failed to ensure medications remained in their original packaging, failed to keep their medication carts clean and sanitary, failed to discard expired medications, and failed to store a medication per manufacturer recommendation for three out of three medications carts reviewed for medication storage.

Inspectors wroteBased on observation, interview and record review the facility failed to keep the door closed and educate visitors on proper Personal Protective Equipment (PPE) to be used when entering a resident room on Contact/Droplet precautions for one (R121) resident, failed to don proper PPE when entering the room of one (R1) resident room with a diagnosis of COVID-19 and failed to ensure clean linen was covered on two second floor linen carts. These failures have the potential to affect 51 residents residing on the second floor. Finding Include: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dignified dining experience for one resident (R114) out of a total sample of 23 residents.

Inspectors wroteBased on interview and record review, the facility failed to update a resident's (R41) care plan to coincide with their requested advanced directive wishes for one out of a final sample of 23 residents.

Inspectors wroteBased on interview and record review, the facility failed to obtain a new Preadmission Screening and Resident Review (PASRR) after a resident's (R101) PASRR Level II short-term approval ended for one out of a total sample of 23 residents.

Inspectors wroteBased on interview and record review, the facility failed to refer residents with newly evident or possible serious mental disorder for Preadmission Screening and Resident Review (PASRR) to the appropriate state-designated authority. This failure affects four (R22, R32, R47, R82) residents in a total sample of 23 residents reviewed.

Inspectors wroteBased on observation, interviews, and review of records the facility failed to follow their policy in providing privacy to 1 out of 1 resident (R94) when providing bedside care for a total sample of 23 residents reviewed.

Inspectors wroteBased on observations, interview and review of records, facility failed to follow a resident's care plan to ensure the call light was within reach for 1 (R98) out of three residents reviewed for call lights in a sample of 23.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide privacy and confidentiality for three (R37, R44, R82) resident's personal medication administration record.

Inspectors wroteBased on observations, interviews and record reviews, facility failed to follow their policy to ensure routine wellbeing checks are done for 1 (R45) out of three residents reviewed for activities of daily living (ADL) care in sample of 23.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their enteral tube feeding via pump policy to ensure 1 (R21) resident's enteral nutrition bottles were labeled before administration in a sample of 23 reviewed for enteral tube feeding.

Inspectors wroteBased on observation, interviews, and review of records the facility failed to provide dental services for a resident who has difficulty chewing due to lack of upper teeth for 1 out of 1 resident (R56) for a total sample of 23 residents.

Inspectors wroteBased on interview and record review, facility failed to follow their policy to provide influenza and pneumococcal vaccination and failed to document resident education for the vaccinations for 3 residents (R43, R45, and R98) out of 5 residents reviewed for vaccinations in a sample of 23.

Inspectors wroteBased on observations, interviews, and record review the facility failed to grant access of the residents' electronic health records to the survey team timely. These failures have the potential to affect all 102 residents in determining a thorough review of residents' records to identify or rule out compliance of state and federal regulation.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to use utensils or wear food handling gloves while handling a resident's (R31) food. The facility also failed to ensure food items were properly stored, failed to ensure staff was performing appropriate hand hygiene in between handling dirty and clean kitchen equipment, and failed to air dry the blender and lid after staff washed it in the three-compartment sink having the potential to affect all 85 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure standardized recipes were followed during pureed food preparation. This failure has the potential to affect 6 residents (R12, R31, R39, R40, R47, R51) out of 85 receiving foods prepared in the facility's kitchen. Findings Include: On 12/06/23 at 11:15 AM, V14 (Dietary Assistant/Cook) stated the pureed consistency should be smooth with no lumps and thick like applesauce. At 11:23 AM, during pureed meal preparation observed V14 add three cups of water and ten pieces of cooked baked fish to the blender before pressing the start button to puree the fish. At 11:26 AM, V14 added an additional one cup water to fish. At 11:27 AM, V14 portioned pureed fish using #8 scoop into individual bowls. There was left over pureed fish in the blender. Surveyor observed the consistency of pureed fish to be thin. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide care in a manner to promote dignity for two residents (R31, R50) reviewed for dignity in a total sample of 18 residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to clarify a physician's order for one (R51) resident out of a total sample of 18 residents reviewed for medications.

Inspectors wroteBased on observation, interview and record review the facility failed to follow their policy to complete a nutritional assessment on residents with a significant change in nutritional status. This failure affected 1 resident (R14) of 6 residents reviewed for nutrition and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care equipment was stored in a manner to prevent possible contamination from viral and/or bacterial pathogens for 3 (R47, R68, R75) of 3 residents reviewed who received respiratory care services in a sample of 18. Findings Include: 1.) R75 has diagnosis not limited to Pneumonia, Dementia with Psychotic Disturbance, Gastrostomy, Cholelithiasis, Gastro-Esophageal Reflux Disease, Dysphagia, Quadriplegia, Seizures, Nutritional Anemias, Age Related Osteoporosis. R75's Physician Orders document I part: Ipratropium-Albuterol 0.5 MG (Milligram)/3 ML (Milliliter) every 4 hours as needed. On 12/02/23 at 11:39 AM R75 was observed sitting in a wheelchair at the bedside. R75's nebulizer mask was observed laying on top of a bag on the stand at the bedside with no protective bag. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to label open insulins for 2 residents (R15, R54) on 1 of 6 medication carts reviewed for medication storage in a sample of 18 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow physician's orders for a specialized diet and update the resident's (R31) comprehensive care plan to correspond to the prescribed diet for one of 18 residents reviewed for nutrition.